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The California AD 9 form, officially known as the Independent Adoption Questionnaire, plays a crucial role in the adoption process within the state. This form is designed for prospective adoptive parents and requires detailed information about both petitioners, including their personal backgrounds, employment details, and family histories. It collects essential data such as names, birth dates, ethnicities, and educational backgrounds, alongside inquiries into criminal histories and any past allegations of child neglect or domestic violence. Additionally, the form asks about previous marriages or domestic partnerships and any children born prior to the current relationship. This comprehensive questionnaire aims to ensure that the adopting parents are thoroughly vetted, promoting the safety and well-being of the child being adopted. Timeliness is also emphasized, as applicants are instructed to complete and return the form within one week, highlighting the importance of efficiency in the adoption process. By gathering this information, the California Department of Social Services seeks to create a safe and nurturing environment for children awaiting adoption.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATE CASE NUMBER:

INDEPENDENT ADOPTION QUESTIONNAIRE

INFORMATION REQUIRED IN THE MATTER OF THE ADOPTION OF:

FIRST PETITIONER’S NAME:

SECOND PETITIONER’S NAME:

CHILD’S NAME:

CHILD’S ADOPTED NAME:

Dear Petitioner(s):

Complete this Independent Adoption Questionnaire (AD 9) and Adoption Questionnaire I (AD 4324) (to be filled out individually) and return them within one week.

Thank You.

__________________________________________________________________________

(NAME OF CDSS DISTRICT OFFICE OR DELEGATED COUNTY ADOPTION AGENCY)

(Please fill out as completely as possible, writing “NA” or “Unknown” where appropriate)

AD 9 (11/07)

PAGE 1 OF 12

I. FIRST PETITIONER’S INFORMATION

LAST NAME

 

 

 

 

FIRST NAME

 

 

 

MIDDLE NAME

 

 

 

 

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

PLACE OF BIRTH

ETHNICITY

 

RACE

 

 

RELIGION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

DRIVER LICENSE NUMBER

EDUCATION

 

OCCUPATION

 

MONTHLY SALARY

 

-

-

 

 

 

 

(HIGHEST GRADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED)

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

 

LENGTH OF EMPLOYMENT

 

WORK HOURS

 

 

 

WORK TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU A UNITED STATES CITIZEN?

DATE OF ARRIVAL IN U.S.

 

DATE OF ARRIVAL IN

 

 

 

 

 

YES NO

 

 

 

 

 

 

CALIFORNIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NATURALIZED

 

 

 

ARE YOU A PERMANENT RESIDENT?

ALIEN REGISTRATION NUMBER

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE:

 

 

 

 

YES NO

 

A-

 

 

 

 

 

 

 

NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILITARY SERVICE:

 

 

 

DATE OF SERVICE:

 

DATE OF DISCHARGE:

 

 

 

 

 

 

 

YES NO

 

 

 

 

 

 

HONORABLE

DISHONORABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

CRIMINAL HISTORY

 

 

 

 

 

 

 

1)

Have you ever been arrested for an offense other than a traffic infraction?

 

 

YES

NO

 

If YES, please explain the charges and any convictions:

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

2)

Are you currently on probation or parole?

 

 

 

 

 

YES

NO

 

If YES, please explain the circumstance:

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

3)

Have you ever been investigated for allegations of child neglect or abuse?

 

 

YES

NO

 

If YES, please explain the circumstances:

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

4)

Have you ever been reported for allegations of domestic violence?

 

 

YES

NO

If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

B.FORMER MARRIAGE(S)/REGISTERED DOMESTIC PARTNERSHIP(S) (RDP)

FULL NAME OF FORMER SPOUSE(S)/RDP(S)

(Give maiden name and current address)

WHERE

(License/Registration Issued in County/State)

MARRIAGE/RDP

(Date & Place)

DIVORCE/RDP TERMINATION

(Date & Place)

DEATH

(Date & Place)

AD 9 (11/07)

PAGE 2 OF 12

C.CHILD(REN) BORN PRIOR TO CURRENT MARRIAGE/REGISTERED DOMESTIC PARTNERSHIP

FULL NAME OF CHILD

DATE OF

BIRTH

EDUCATION

(Name & Address of School & Grade)

HEALTH CONDITIONS

IF ADOPTED

(Place, Date, Agency)

1)

Have any of your children ever been arrested for an offense other than a traffic infraction?

YES

NO

 

If YES, please explain the charges and any convictions:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

2)

Are any of your children currently on probation or parole?

YES

NO

 

If YES, please explain the circumstance:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

3)

Have any of your adult children ever been investigated for allegations of child neglect or abuse?

YES

NO

 

If YES, please explain the circumstances:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

4)

Have any of your adult children ever been reported for allegations of domestic violence?

YES

NO

If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

 

D.

FAMILY HISTORY

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

 

HEALTH

DATE OF

RELATIVES’ NAMES

ADDRESS

(Highest Grade OCCUPATION

AGE

DEATH

CONDITIONS

 

 

Completed)

 

(If Deceased)

 

 

 

 

FATHER

MOTHER

SIBLING

SIBLING

SIBLING

AD 9 (11/07)

PAGE 3 OF 12

II. SECOND PETITIONER’S INFORMATION

LAST NAME

 

 

 

 

FIRST NAME

 

 

 

MIDDLE NAME

 

 

 

 

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

PLACE OF BIRTH

ETHNICITY

 

RACE

 

 

RELIGION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

DRIVER LICENSE NUMBER

EDUCATION

 

OCCUPATION

 

MONTHLY SALARY

 

-

-

 

 

 

 

(HIGHEST GRADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED)

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND ADDRESS OF EMPLOYER

 

LENGTH OF EMPLOYMENT

 

WORK HOURS

 

 

 

WORK TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU A UNITED STATES CITIZEN?

DATE OF ARRIVAL IN U.S.

 

DATE OF ARRIVAL IN

 

 

 

 

 

YES NO

 

 

 

 

 

 

CALIFORNIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NATURALIZED

 

 

 

ARE YOU A PERMANENT RESIDENT?

ALIEN REGISTRATION NUMBER

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE:

 

 

 

 

YES NO

 

A-

 

 

 

 

 

 

 

NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILITARY SERVICE:

 

 

 

DATE OF SERVICE:

 

DATE OF DISCHARGE:

 

 

 

 

 

 

 

YES NO

 

 

 

 

 

 

HONORABLE

DISHONORABLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

CRIMINAL HISTORY

 

 

 

 

 

 

 

1)

Have you ever been arrested for an offense other than a traffic infraction?

 

 

YES

NO

 

If YES, please explain the charges and any convictions:

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

2)

Are you currently on probation or parole?

 

 

 

 

 

YES

NO

 

If YES, please explain the circumstance:

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

3)

Have you ever been investigated for allegations of child neglect or abuse?

 

 

YES

NO

 

If YES, please explain the circumstances:

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

4)

Have you ever been reported for allegations of domestic violence?

 

 

YES

NO

If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

B.FORMER MARRIAGE(S)/REGISTERED DOMESTIC PARTNERSHIP(S) (RDP)

FULL NAME OF FORMER SPOUSE/REGISTERED

DOMESTIC PARTNER

(Give maiden name and current address)

WHERE

(License/Registration Issued in

County/State)

MARRIAGE/RDP

(Date & Place)

DIVORCE/RDP TERMINATION

(Date & Place)

DEATH

(Date & Place)

AD 9 (11/07)

PAGE 4 OF 12

C. CHILD(REN) BORN PRIOR TO CURRENT MARRIAGE/REGISTERED DOMESTIC PARTNERSHIP

FULL NAME OF CHILD

DATE OF

BIRTH

EDUCATION

(Name & Address of School & Grade)

HEALTH CONDITIONS

IF ADOPTED

(Place, Date, Agency)

1)

Have any of your children ever been arrested for an offense other than a traffic infraction?

YES

NO

 

If YES, please explain the charges and any convictions:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

2)

Are any of your children currently on probation or parole?

YES

NO

 

If YES, please explain the circumstance:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

3)

Have any of your adult children ever been investigated for allegations of child neglect or abuse?

YES

NO

 

If YES, please explain the circumstances:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

4)

Have any of your adult children ever been reported for allegations of domestic violence?

YES

NO

If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

 

D.

FAMILY HISTORY

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

 

HEALTH

DATE OF

RELATIVES’ NAMES

ADDRESS

(Highest Grade OCCUPATION

AGE

DEATH

CONDITIONS

 

 

Completed)

 

(If Deceased)

 

 

 

 

FATHER

MOTHER

SIBLING

SIBLING

SIBLING

AD 9 (11/07)

PAGE 5 OF 12

III. HOUSEHOLD INFORMATION

MAILING ADDRESS

CITY, STATE, ZIP

 

HOW LONG AT PRESENT ADDRESS

 

 

 

I. CELLULAR PHONE NUMBER

II. CELLULAR PHONE NUMBER

HOME TELEPHONE NUMBER

(

)

(

)

 

(

)

 

 

 

 

 

If you are a married or registered domestic couple:

 

If you are an unmarried couple:

 

 

DATE OF MARRIAGE/REGISTRATION:

 

LENGTH OF DOMESTIC PARTNERSHIP/RELATIONSHIP:

 

 

 

 

 

 

 

PLACE OF MARRIAGE/REGISTRATION:

 

HAVE YOU FILED A REGISTRATION OF DOMESTIC PARTNERSHIP WITH THE SECRETARY OF STATE?

 

YES NO

 

 

 

(CITY, COUNTY AND STATE)

 

IF YES, DATE OF FILING:_______________________________________________

 

 

 

 

 

 

 

DESCRIBE YOUR HOME (INCLUDE NUMBER OF BEDROOMS & BATHROOMS):

DIRECTIONS TO YOUR HOME:

HAVE YOU EVER HAD ANY PREVIOUS ADOPTIVE PLACEMENT(S)?

YES

NO IF YES, PLEASE DESCRIBE:

 

 

 

HAVE YOU EVER APPLIED WITH ANOTHER AGENCY?

YES

NO

IF YES, WHEN AND NAME OF AGENCY:

 

 

 

 

 

A.CHILD(REN) OF PETITIONER(S)

FULL NAME OF CHILD

DATE OF

BIRTH

EDUCATION

(Name & Address of School & Grade)

HEALTH CONDITIONS

IF ADOPTED

(Place, Date, Agency)

1)

Have any of your children ever been arrested for an offense other than a traffic infraction?

YES

NO

 

If YES, please explain the charges and any convictions:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

2)

Are any of your children currently on probation or parole?

YES

NO

 

If YES, please explain the circumstance:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

3)

Have any of your adult children ever been investigated for allegations of child neglect or abuse?

YES

NO

 

If YES, please explain the circumstances:

 

 

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

 

______________________________________________________________________________________________________

4)

Have any of your adult children ever been reported for allegations of domestic violence?

YES

NO

If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

AD 9 (10/03)

PAGE 6 OF 12

B.OTHER MEMBERS OF THE HOUSEHOLD

FULL NAME

GENDER DATE OF BIRTH RELATIONSHIP TO FAMILY

OCCUPATION

1)Have any of these members of the household ever been arrested for an offense other than a

traffic infraction?

YES NO

If YES, please explain the charges and any convictions:

 

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

2) Are any of these members of the household currently on probation or parole?

YES NO

If YES, please explain the circumstance:

 

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

3)Have any of these members of the household ever been investigated for allegations of child

neglect or abuse?

YES NO

If YES, please explain the circumstances:

 

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

4) Have any of these members of the household ever been reported for allegations of domestic violence? YES NO If YES, please explain the circumstances and outcome:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

IV. BIRTHPARENT/LEGAL PARENT INFORMATION

 

BIRTHMOTHER/LEGAL PARENT

 

 

BIRTHFATHER/LEGAL PARENT

NAME (LAST, FIRST, MIDDLE)

 

NAME (LAST, FIRST, MIDDLE)

 

 

 

 

 

MAIDEN NAME OR ALIASES

 

ALIASES

 

 

 

 

 

 

 

ETHNICITY, RACE

BIRTHDATE

ETHNICITY, RACE

 

BIRTHDATE

 

 

 

 

 

ADDRESS

 

ADDRESS

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

TELEPHONE NUMBER

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

A.PLACEMENT DETAILS

DESCRIBE FULLY HOW YOU FIRST LEARNED OF THE CHILD, IF AND WHEN YOU MET THE BIRTHPARENTS/LEGAL PARENT, AND HOW YOU SECURED THIS CHILD FOR ADOPTION. INCLUDE SPECIFIC INFORMATION PERTAINING TO THE TRANSFER OF CUSTODY AND THE NAME OF ANY INTERMEDIARY INVOLVED.

AD 9 (11/07)

PAGE 7 OF 12

B.EXPENSES RELATED TO ADOPTION

HOSPITAL

ADOPTION SERVICE

PROVIDER

PHYSICIAN

ATTORNEY

BIRTHPARENT/ LEGAL PARENT

OTHER

C.CONCERNING CHILD(REN) TO BE ADOPTED

 

 

 

 

CHILD #1

 

 

 

 

 

 

CHILD #2

 

 

NAME OF CHILD

 

 

 

 

 

 

NAME OF CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

PLACE OF BIRTH

 

 

GENDER

 

DATE PLACED IN HOME

BIRTHDATE

 

 

PLACE OF BIRTH

GENDER

DATE PLACED IN HOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF HOSPITAL

 

 

 

 

 

 

NAME OF HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS OF HOSPITAL

 

 

 

 

 

 

ADDRESS OF HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTENDING PHYSICIAN

 

 

 

 

 

 

ATTENDING PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEIGHT

 

 

WEIGHT

 

EYE COLOR

 

HAIR COLOR

HEIGHT

 

WEIGHT

 

EYE COLOR

 

HAIR COLOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAS THE CHILD EVER BEEN KNOWN BY ANOTHER NAME?

 

 

HAS THE CHILD EVER BEEN KNOWN BY ANOTHER NAME?

 

YES

NO

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT AGE

 

CURRENT WEIGHT

 

 

CURRENT AGE

 

 

CURRENT WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU BELIEVE THE CHILD WAS EXPOSED TO ALCOHOL OR DRUGS IN UTERO?

DO YOU BELIEVE THE CHILD WAS EXPOSED TO ALCOHOL OR DRUGS IN UTERO?

YES

NO

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU BELIEVE OR SUSPECT THE CHILD WAS SUBJECTED TO

 

 

DO YOU BELIEVE OR SUSPECT THE CHILD WAS SUBJECTED TO

 

PHYSICAL, SEXUAL OR EMOTIONAL ABUSE OR NEGLECT PRIOR

 

YES NO

PHYSICAL, SEXUAL OR EMOTIONAL ABUSE OR NEGLECT PRIOR

YES NO

TO PLACEMENT IN YOUR HOME?

 

 

 

 

 

TO PLACEMENT IN YOUR HOME?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YES, PLEASE PROVIDE DETAILS:

 

 

 

 

 

 

IF YES, PLEASE PROVIDE DETAILS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BRIEFLY DESCRIBE THE ADJUSTMENT OF YOUR CHILD(REN) TO YOUR HOME:

DESCRIBE CURRENT AND FUTURE PLANNED CHILD CARE ARRANGEMENTS:

DESCRIBE, IF ANY, RELIGIOUS TRAINING PLANS OF THE CHILD(REN):

D.SCHOOL INFORMATION (COMPLETE THIS SECTION IF CHILD(REN) ATTENDS SCHOOL)

NAME OF SCHOOL

 

NAME OF SCHOOL

 

 

 

 

 

SCHOOL ADDRESS

 

SCHOOL ADDRESS

 

 

 

 

 

SCHOOL PHONE

GRADE LEVEL

SCHOOL PHONE

GRADE LEVEL

(

)

 

(

)

 

 

 

 

 

REGISTERED NAME

TEACHER’S NAME

REGISTERED NAME

TEACHER’S NAME

 

 

 

 

 

 

AD 9 (11/07)

PAGE 8 OF 12

V.FINANCIAL INFORMATION

MONTHLY INCOME

 

 

 

 

GROSS WAGES

 

 

 

 

First Petitioner

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ __________________

Second Petitioner

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ __________________

NET WAGES

 

 

 

 

First Petitioner

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

$ ______________________

Second Petitioner

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

$ ______________________

OTHER INCOME (interest, property, dividends, etc.)

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

 

 

 

TOTAL GROSS INCOME

$ ___________________

MONTHLY EXPENSES

 

 

 

 

Housing (include taxes, insurance, & utilities)

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

Insurance

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

Food/Clothing

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

Legal Obligations (child support, alimony, etc.)

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

Extraordinary Expenses

. . . . . . . . . . . . . . . . . . . . . . . . .

. .

. . . . . . . . . . . . . . . . . . . . . . . .

$ ___________________

 

MONTHLY CONSUMER DEBT PAYMENTS

 

 

 

 

 

 

ITEM

TERMINATION DATE

 

BALANCE DUE

MONTHLY PAYMENT

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

TOTAL

$

 

$

 

 

 

 

 

 

 

 

 

 

If you own your home, please indicate the following:

Purchase Price

$ ___________________

Balance Due

$ _____________________

FINANCIAL ASSETS

 

 

 

Savings

$ ___________________

Investments

$ _____________________

Stocks, Bonds

$ ___________________

Real Property

$ _____________________

Other Resources

$ ___________________

 

 

If you are self-employed or an employer cannot verify your income for some other reason, please attach a copy of your last year’s federal income tax return.

I/We filed both state and federal income tax returns last year.

YES NO If NO, state reason: __________________________________________________________________________

I/We have had the occasion to file for bankruptcy.

YES NO

If YES, state reason: _________________________________________________________________________

PLEASE USE THIS SPACE TO NOTE ANY ADDITIONAL FINANCIAL INFORMATION THAT YOU BELIEVE THE DEPARTMENT SHOULD BE AWARE OF:

AD 9 (11/07)

PAGE 9 OF 12

VI. INSURANCE

Does your family have health and hospitalization insurance that covers all family members? YES NO

If YES, indicate the name of insurance carrier and address:____________________________________________________________

___________________________________________________________________________________________________________

Name and address of family physician:____________________________________________________________________________

___________________________________________________________________________________________________________

Name and address of pediatrician: _______________________________________________________________________________

___________________________________________________________________________________________________________

What provisions for medical care will be provided for the child(ren)?_____________________________________________________

___________________________________________________________________________________________________________

Check the types of insurance coverage your family has and briefly describe each coverage.

Life Insurance: __________________________________________________________________________________________

______________________________________________________________________________________________________

Disability Insurance: ______________________________________________________________________________________

______________________________________________________________________________________________________

Automobile Insurance: ____________________________________________________________________________________

______________________________________________________________________________________________________

Renters/Home Owners Insurance: ___________________________________________________________________________

______________________________________________________________________________________________________

Other Policies: __________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

NOTE: California law (Section 1373(c) of the Health and Safety Code, and Sections 10119, 10112, and 11512.1 of the Insurance Code) requires that effective January 1, 1988, all health care service plans provide accident and sickness coverage to each minor child placed for adoption from and after the moment the child is placed in the physical custody of the covered subscriber or enrollee of adoption.

AD 9 (11/07)

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Form Specifications

Fact Name Details
Form Purpose The California AD 9 form is an Independent Adoption Questionnaire used to gather essential information from prospective adoptive parents.
Governing Laws This form is governed by the California Family Code, specifically sections related to adoption procedures and requirements.
Submission Timeline Petitioners must complete and return the AD 9 form along with the Adoption Questionnaire I (AD 4324) within one week of receipt.
Information Required The form requests detailed personal information, including criminal history, family background, and employment details of the petitioners.
Confidentiality Information provided in the AD 9 form is treated with confidentiality and is used solely for the adoption assessment process.

California Ad 9: Usage Guidelines

Filling out the California AD 9 form requires careful attention to detail. The form collects essential information about the petitioners and their family background as part of the adoption process. Ensure that all sections are completed accurately to facilitate the review process.

  1. Obtain the California AD 9 form from the California Department of Social Services or a relevant adoption agency.
  2. At the top of the form, enter the State Case Number associated with your adoption case.
  3. Fill in the names of the petitioners and the child involved in the adoption:
    • First Petitioner's Name
    • Second Petitioner's Name
    • Child’s Name
    • Child’s Adopted Name
  4. Provide the first petitioner's information, including:
    • Last Name, First Name, Middle Name
    • Gender, Birthdate, Place of Birth
    • Ethnicity, Race, Religion
    • Social Security Number, Driver License Number
    • Education, Occupation, Monthly Salary
    • Name and Address of Employer, Length of Employment, Work Hours, Work Telephone Number
    • Citizenship status and relevant dates
    • Military service details, if applicable
  5. Answer questions regarding criminal history, including arrests and investigations related to child neglect or domestic violence. Provide explanations where necessary.
  6. If applicable, fill out details regarding former marriages or registered domestic partnerships, including names, dates, and circumstances.
  7. Provide information about children born prior to the current marriage or partnership, including their names, dates of birth, education, and health conditions.
  8. Repeat the same process for the second petitioner, ensuring all sections are completed as done for the first petitioner.
  9. Complete the family history section, listing relatives' names, addresses, occupations, and any relevant health conditions.
  10. Review the entire form for accuracy and completeness before submission.
  11. Submit the completed form to the designated CDSS district office or delegated county adoption agency within one week.

Your Questions, Answered

What is the California AD 9 form?

The California AD 9 form, also known as the Independent Adoption Questionnaire, is a document required by the California Department of Social Services for individuals looking to adopt a child independently. It collects essential information about the petitioners, including personal details, criminal history, family background, and information about any previous marriages or domestic partnerships. Completing this form is a crucial step in the adoption process, as it helps ensure the safety and well-being of the child being adopted.

Who needs to fill out the AD 9 form?

Both petitioners intending to adopt must complete the AD 9 form. This includes the first and second petitioners, regardless of their marital status. Each petitioner must provide their personal information, background details, and any relevant history that may impact the adoption process. It's important for both individuals to be transparent and thorough in their responses to facilitate a smooth adoption experience.

What information is required on the AD 9 form?

The AD 9 form requires a variety of information. This includes the petitioners' names, birthdates, social security numbers, education levels, and employment details. Additionally, the form asks about criminal history, including arrests and investigations related to child neglect or abuse. Information about previous marriages or domestic partnerships, as well as details about any children from those relationships, is also necessary. Providing complete and accurate information is vital for the adoption process.

How long do I have to submit the AD 9 form?

Once you receive the AD 9 form, you are typically required to return it within one week. This timeline is important to keep the adoption process moving forward. If you anticipate needing more time to gather the necessary information, it's advisable to communicate with the relevant adoption agency or district office as soon as possible to discuss your situation.

What happens if I have a criminal history?

If you have a criminal history, it is essential to disclose this information on the AD 9 form. The form specifically asks about arrests, convictions, and any investigations related to child neglect or abuse. While having a criminal history does not automatically disqualify you from adopting, it will be reviewed as part of the overall assessment process. Being honest about your past can help the adoption agency make informed decisions regarding your suitability as an adoptive parent.

Can I fill out the AD 9 form online?

Currently, the AD 9 form is typically a paper form that must be filled out and submitted in person or via mail. However, some adoption agencies may provide resources or guidance for completing the form electronically. It’s best to check with the specific agency handling your adoption for their preferred submission methods and any available online options.

What should I do if I don’t have all the information requested?

If you do not have all the information requested on the AD 9 form, you should fill in as much as you can and indicate "NA" (not applicable) or "Unknown" where appropriate. It's better to provide partial information than to leave sections completely blank. If you have questions about specific sections or need assistance, consider reaching out to the adoption agency for guidance.

Where can I find more information about the adoption process in California?

For more information about the adoption process in California, you can visit the California Department of Social Services website. They provide comprehensive resources, including guidelines, forms, and contact information for local adoption agencies. Additionally, many community organizations offer support and information for prospective adoptive parents, which can be invaluable as you navigate this journey.

Common mistakes

  1. Incomplete Information: Many people forget to fill out all sections of the form. It’s essential to provide complete details for each question. If a question doesn’t apply, write “NA” or “Unknown” instead of leaving it blank.

  2. Missing Signatures: Failing to sign the form can delay the process. Ensure that both petitioners sign the form where indicated before submission.

  3. Incorrect Dates: Providing wrong dates, especially for important events like marriage or divorce, can lead to complications. Double-check all dates for accuracy.

  4. Omitting Background Information: Some individuals may hesitate to disclose past arrests or investigations. However, being transparent is crucial. If there are any relevant incidents, they should be explained in detail.

  5. Ignoring the Deadline: Submitting the form after the one-week deadline can cause delays in the adoption process. Set reminders to ensure timely submission.

  6. Not Keeping a Copy: Failing to make a copy of the completed form for personal records can be a mistake. It’s wise to keep a copy for reference in case any questions arise later.

Documents used along the form

The California Ad 9 form serves as an essential document in the independent adoption process, gathering detailed information about the prospective adoptive parents. Alongside this form, several other documents are typically required to ensure a comprehensive evaluation of the adopting individuals and their suitability for adoption. Below is a brief overview of four additional forms often used in conjunction with the California Ad 9.

  • Adoption Questionnaire I (AD 4324): This form is filled out by each petitioner individually. It collects personal information similar to the Ad 9, including details about education, employment, and family background. The purpose of this questionnaire is to provide a deeper understanding of the petitioners' circumstances and readiness to adopt.
  • Criminal Background Check Authorization: This document allows the relevant authorities to conduct a thorough background check on the prospective adoptive parents. It is crucial for ensuring the safety and well-being of the child, as it helps identify any potential risks associated with the petitioners' past behavior.
  • Home Study Report: Conducted by a licensed social worker or adoption agency, this report evaluates the home environment of the prospective adoptive parents. It assesses their living conditions, parenting skills, and overall readiness to adopt. The home study is a critical step in the adoption process, providing insights into the family's dynamics and support systems.
  • Financial Disclosure Statement: This document requires the petitioners to disclose their financial situation, including income, assets, and liabilities. The purpose of this statement is to ensure that the adopting parents can provide for the child's needs, both now and in the future.

In summary, the adoption process in California involves multiple forms and documents that work together to create a comprehensive picture of the prospective adoptive parents. Each document serves a distinct purpose, contributing to the overall assessment of the family's readiness and ability to provide a nurturing environment for the child.

Similar forms

  • Adoption Questionnaire I (AD 4324): This document is also part of the adoption process in California. Similar to the AD 9, it collects detailed personal information about the petitioners, including their backgrounds and circumstances. Both forms are designed to ensure that the adoption agency has a comprehensive understanding of the petitioners' lives.
  • California Adoption Agreement: This legal document formalizes the adoption process. Like the AD 9, it outlines the responsibilities and rights of the adoptive parents. It serves to ensure that all parties are aware of the legal implications of the adoption, similar to how the AD 9 gathers pertinent information for evaluation.
  • Home Study Report: Conducted by a licensed social worker, this report assesses the home environment of the prospective adoptive parents. It shares similarities with the AD 9 in that both documents aim to evaluate the suitability of the petitioners for adoption, focusing on their backgrounds and current living situations.
  • Child’s Medical History Form: This form provides essential health information about the child being adopted. Like the AD 9, it is crucial for making informed decisions regarding the child's welfare and future care, ensuring that the adoptive parents are aware of any medical needs.
  • Consent to Adopt Form: This document is signed by the biological parents or guardians, giving permission for the adoption to proceed. It parallels the AD 9 in its importance within the adoption process, as both forms are necessary for legal compliance and the protection of all parties involved.
  • Post-Adoption Agreement: This document outlines the terms of contact between the adoptive family and the biological family after the adoption is finalized. Like the AD 9, it aims to provide clarity and understanding regarding the relationships and expectations that will exist following the adoption.

Dos and Don'ts

When filling out the California AD 9 form, it’s important to ensure accuracy and completeness. Here’s a list of things you should and shouldn’t do:

  • Do read the instructions carefully before starting.
  • Do provide accurate information for all sections.
  • Do write “NA” or “Unknown” where applicable.
  • Do return the completed form within one week.
  • Don't leave any required fields blank.
  • Don't provide false or misleading information.
  • Don't forget to sign and date the form.
  • Don't submit the form without reviewing it for errors.

Misconceptions

When it comes to the California AD 9 form, many people hold misconceptions that can lead to confusion or mistakes in the adoption process. Here are four common misunderstandings:

  • It's Only for Couples: Many believe that the AD 9 form is exclusively for couples looking to adopt. In reality, both single individuals and couples can use this form to initiate the independent adoption process. Whether you are a single parent or part of a couple, you are eligible to fill out the AD 9.
  • Information is Optional: Some think that they can skip questions they find uncomfortable or irrelevant. However, the form requires complete and accurate information. Providing thorough details helps the adoption agency assess your suitability as an adoptive parent.
  • Criminal History is a Dealbreaker: There’s a misconception that any criminal history automatically disqualifies a potential adoptive parent. While a history of certain offenses may raise concerns, each case is evaluated individually. Transparency about your past is crucial and can lead to a more informed decision by the agency.
  • It’s a Quick Process: Many assume that completing the AD 9 form is a quick step in the adoption process. In truth, while filling out the form may seem straightforward, the entire adoption process can take time. The AD 9 is just one part of a more extensive procedure that involves home studies, background checks, and more.

Understanding these misconceptions can help streamline the adoption journey and ensure that all necessary steps are taken with clarity and confidence.

Key takeaways

The California AD 9 form is an essential document for those pursuing independent adoption. Here are some key takeaways to keep in mind when filling it out:

  • Complete Information: Fill out the form as completely as possible. If something does not apply, write “NA” or “Unknown.”
  • Timely Submission: Return the completed AD 9 form within one week to ensure the adoption process stays on track.
  • Petitioner Details: Provide detailed information for both petitioners, including names, birthdates, and contact information.
  • Criminal History: Disclose any arrests or investigations related to child neglect, abuse, or domestic violence. Transparency is crucial.
  • Family Background: Include information about former marriages or domestic partnerships, along with any children from those relationships.
  • Children’s Information: If applicable, provide details about children born before the current marriage or partnership, including their education and health conditions.
  • Employer Information: List your current employer, job title, salary, and work hours. This helps assess your stability.
  • Citizenship Status: Indicate whether you are a U.S. citizen or a permanent resident, and provide relevant dates of arrival.
  • Military Service: If applicable, include details about military service, including dates and discharge status.

Understanding these key points can simplify the process and help ensure that your application is complete and accurate. Good luck with your adoption journey!